Lidocaine Hydrochloride (Local) Dosage and Administration

General

Determine dosage based on type and extent of surgical procedure, area to be anesthetized, vascularity of tissues, depth and duration of anesthesia, degree of muscular relaxation, and condition of the patient.211213 Use lowest concentration and smallest dose required to produce the desired effect.211213214

Administration

Injection

For solution and drug compatibility information, see Compatibility under Stability.

Administer by local infiltration, peripheral nerve block, paracervical block, sympathetic nerve block, central neural block (e.g., epidural block), caudal block, or subarachnoid (spinal) block.211213214 Has been administered by continuous intra-articular infusion† (e.g., for control of postoperative pain); however, such use associated with chondrolysis.200201202203204205206207208209211212 (See Risk of Chondrolysis Associated with Intra-articular Infusions of Local Anesthetics under Cautions.)

Consult specialized references for specific techniques and procedures for administering local anesthetics.211213214

For caudal or lumbar epidural block, avoid rapid injection of large volumes; when feasible, administer in fractional (incremental) doses.211

For epidural or spinal block, avoid using preparations containing antimicrobial preservatives (e.g., methylparaben), since safety of intrathecal administration using these preparations not established.211

For dental anesthesia, lidocaine hydrochloride 2% solution with epinephrine 1:100,000 preferred for most routine procedures; when greater depth and a more pronounced hemostasis are required, use preparation containing epinephrine 1:50,000.213

For chemical disinfection of container surface, moisten cotton or gauze with isopropyl (rubbing) alcohol (91%) or ethyl alcohol (70%) and wipe surface thoroughly just prior to use.211213 Do not use alcohol brands that are not of USP grade, since these preparations may contain denaturants that may be injurious to rubber.211213

Dilution

Dosage

Available as lidocaine hydrochloride, as fixed combination containing lidocaine hydrochloride and epinephrine bitartrate or epinephrine hydrochloride, and as lidocaine hydrochloride in dextrose injection.211213214 Dosage expressed in terms of lidocaine hydrochloride.211213214

Transtracheal Injection

If both transtracheal injection and topical application (oropharyngeal spray) are needed to achieve complete analgesia, combined total dose from transtracheal injection and oropharyngeal spray should be ≤200 mg (5 mL) of 4% solution or ≤3 mg/kg.212

Prescribing Limits

Pediatric Patients

Local or Regional Anesthesia

For children >3 years of age with normal lean body mass and normal development, maximum dose is determined by child’s age and weight.211 For example, dosage for a 5-year old child weighing 50 lbs should not exceed 75–100 mg (3.3–4.4 mg/kg or 1.5–2 mg/lb).211 For IV regional anesthesia, maximum 3 mg/kg (1.4 mg/lb), using more dilute solutions (e.g., lidocaine hydrochloride 0.25 or 0.5% solution).211 (See Dilution under Dosage and Administration: Administration.)

Anesthesia in Maxillary and Mandibular Area (for oral surgery)

For children <10 years of age with normal lean body mass and normal development, maximum dose is determined by using standard pediatric drug formulas (e.g., Clark’s rule).213 For example, dosage for a 5-year old child weighing 50 lbs should not exceed 75–100 mg (3.3–4.4 mg/kg or 1.5–2 mg/lb).213

Other Populations

Cautions for Lidocaine Hydrochloride (Local)

Contraindications

Contraindications to spinal anesthesia: severe hemorrhage, shock, heart block, local infection at site of proposed puncture, and septicemia.214

Known hypersensitivity to local anesthetics of the amide type or to any ingredient in the formulation.211213214

Warnings/Precautions

Warnings

Experience of Supervising Clinician

Should be used only by clinicians who are sufficiently knowledgeable in the diagnosis and management of dose-related toxicity and other acute emergencies that might arise. 211212213214 Oxygen, resuscitative equipment, drugs, and personnel required for treatment of adverse reactions must be immediately available.211212213214 Delay in proper management of dose-related toxicity, underventilation, and/or altered sensitivity may result in acidosis, cardiac arrest, and, possibly, death.211212213214

Risk of Chondrolysis Associated with Intra-articular Infusions of Local Anesthetics

Chondrolysis (necrosis and destruction of articular cartilage) reported in patients receiving continuous intra-articular infusions of local anesthetics, administered for 48–72 hours via elastomeric infusion devices, for treatment of postoperative pain.200201202203204205206207208209211212 Primarily observed in the shoulder joint following arthroscopic or other shoulder surgery.200211212 May result in long-term disability; often requires intervention (e.g., debridement, arthroplasty).200202203204205206209211212 Not known whether the drug, infusion device, and/or other factors contributed to the development of chondrolysis.200201 Neither local anesthetics nor elastomeric infusion devices are approved for use for continuous intra-articular infusion therapy.200201211212

Risk of nerve injury with use of small-bore needles and microcatheters for spinal anesthesia; possibly a result of drug pooling and inconsistent distribution of concentrated anesthetic within the subarachnoid space.214 If an incomplete or patchy block occurs and is not responsive to patient repositioning, the drug may be missplaced or inadequately distributed.214 Use of a spinal needle of sufficient gauge may facilitate intrathecal distribution; in clinical trials, 22- and 25-gauge spinal needles were used safely for single-injection lidocaine spinal anesthesia.214 Animal studies suggest that dilution of 5% lidocaine hydrochloride with an equal volume of CSF or preservative-free 0.9% sodium chloride may decrease risk of nerve injury from pooling of concentrated drug.214

Use with caution in patients with impaired cardiovascular function, severe shock, or heart block.211213214

Some lidocaine hydrochloride preparations contain epinephrine; risk of exaggerated vasoconstrictor response in patients with peripheral or hypertensive vascular disease.211213 Use with caution and in carefully restricted quantities in areas of the body supplied by end arteries or having otherwise compromised blood supply (e.g., digits, nose, external ear, penis).211213

Familial Malignant Hyperthermia

Many drugs used during the conduct of anesthesia may trigger familial malignant hyperthermia; not known whether amide-type local anesthetics trigger this reaction.211213214 However, standard protocol for management should be available.211213214 Early unexplained signs of tachycardia, tachypnea, labile BP, and metabolic acidosis may precede temperature elevation.211213214 If familial malignant hyperthermia is confirmed, discontinue triggering agent and initiate appropriate therapy (e.g., oxygen, dantrolene) and other supportive measures.211213214

Preexisting Conditions

Conditions that may preclude the use of spinal anesthesia (depending upon the clinician’s evaluation of the situation and ability to manage potential complications) include preexisting CNS disease (e.g., disease associated with pernicious anemia, poliomyelitis, paralysis from nerve injuries and syphilis); hematological disorders predisposing to coagulopathies; current anticoagulant therapy; chronic backache; preoperative headache; hypotension or hypertension; technical problems (persistent paresthesias, persistent bloody spinal tap); arthritis or spinal deformity; extremes of age; and psychosis or other causes of poor patient cooperation.214

Risks Associated with Various Administration Techniques

Paracervical block: Possible rapid systemic absorption.211 Maternal seizures and cardiovascular collapse reported following paracervical block with certain local anesthetics (used to induce anesthesia for elective abortion).211 Administer dose slowly; do not exceed recommended maximum dose.211 (See Administration and see Prescribing Limits, under Dosage and Administration and also see Labor and Delivery under Cautions.)

Potential for life-threatening adverse effects (e.g., irregular heart beat, seizures, breathing difficulties, coma, death) when topical local anesthetics are applied to a large area of skin, when the area of application is covered with an occlusive dressing, if a large amount of topical anesthetic is applied, if the anesthetic is applied to irritated or broken skin, or if the skin temperature increases (from exercise or use of a heating pad).101102

Lidocaine 4% gel has been investigated to reduce discomfort during mammography.101103 Whether such use could result in serious reactions has not been determined.101103 Patients should speak with their clinician if they are considering using a topical anesthetic before obtaining a mammogram.101

When a topical anesthetic is needed for a procedure, use of an FDA-approved preparation has been recommended.e Use a preparation containing the lowest concentration of anesthetic likely to be effective; apply a small amount of the preparation to the affected area for the shortest period necessary for the desired effect, and do not apply to broken or irritated skin.101

Use of Fixed Combination

When used in fixed combination with other agents, consider the cautions, precautions, and contraindications associated with the concomitant agents.

Epidural and spinal anesthesia may prolong second stage of labor (by removing parturient’s reflex urge to bear down or by interfering with motor function); may increase need for forceps assistance.211214

Possible diminished muscle strength and tone on neonate’s first or second day of life.211

Lactation

Not known whether lidocaine is distributed into milk.211213214 Caution if used in nursing women.211213214

Pediatric Use

Safety and efficacy of lidocaine hydrochloride in dextrose injection not established in pediatric patients <16 years of age.214

Onset

For dental anesthesia, onset <2 minutes following infiltration with 2% solution (with or without epinephrine).213 Onset of 2–4 minutes following nerve block with 2% solution (with or without epinephrine).213

Duration

Duration of about 100 minutes following lumbar epidural block with 2% solution.a

Duration of about 75–135 minutes following caudal block with 1 or 2% solution.a

Following spinal block with 50 mg (1 mL) of 5% solution, duration of perineal anesthesia is about 100 minutes; analgesic effects continue for another 40 minutes.214 Duration of surgical anesthesia is about 2 hours with 75–100 mg (1.5–2 mL) of 5% solution.214

For dental anesthesia, pulp anesthesia persists for 5 minutes following infiltration with 2% solution without epinephrine.213 Pulp anesthesia persists for at least 60 minutes following infiltration with 2% solution with epinephrine; average duration of soft tissue anesthesia is approximately 2.5 hours.213 Following nerve block with the 2% solution with epinephrine, pulp anesthesia persists for at least 90 minutes, and soft tissue anesthesia persists for 3.25 hours.213

Actions

Local anesthetics block the generation and conduction of nerve impulses by increasing the threshold for electrical excitation, slowing the propagation of the nerve impulse, and reducing the rate of rise of the action potential.211213214

Some preparations formulated with epinephrine to decrease lidocaine’s rate and extent of systemic absorption and to prolong its duration of action.a211213

Advice to Patients

Prior to administration, advise patients of the possibility of temporary loss of sensation and muscle function (e.g., in lower half of body following lumbar epidural or subarachnoid block).211213214

Advise patients to avoid inadvertent trauma to the lips, tongue, cheek mucosae, or soft palate when these structures are anesthetized for dental procedures; postpone ingestion of food until normal function returns.213 Advise patient to consult dentist if anesthesia persists or if rash develops.213

Importance of informing clinicians of existing or contemplated therapy, including prescription and OTC drugs, as well as any concomitant illnesses (e.g., cardiovascular or liver disease).211213214

Importance of women informing their clinician if they are or plan to become pregnant or plan to breast-feed.211213214

Importance of informing patients of other important precautionary information. 211213214 (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Lidocaine Hydrochloride

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

Injection

0.5%*

Lidocaine Hydrochloride Injection

Xylocaine

APP Pharmaceuticals

Xylocaine-MPF

APP Pharmaceuticals

1%*

Lidocaine Hydrochloride Injection

Xylocaine

APP Pharmaceuticals

Xylocaine-MPF

APP Pharmaceuticals

1.5%*

Lidocaine Hydrochloride Injection

Xylocaine-MPF

APP Pharmaceuticals

2%*

Lidocaine Hydrochloride Injection

Xylocaine

APP Pharmaceuticals

Xylocaine Dental (available as dental cartridge)

Dentsply

Xylocaine-MPF

APP Pharmaceuticals

4%*

Lidocaine Hydrochloride Injection

Xylocaine-MPF Sterile Solution

APP Pharmaceuticals

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Lidocaine Hydrochloride in Dextrose

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

Injection

5% Lidocaine Hydrochloride in 7.5% Dextrose*

Lidocaine Hydrochloride Injection in Dextrose

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name